Form 21-4192 Request for Employment Information in Connection with Cl

OMB Control No. 2900-0065
Respondent Burden: 15 minutes
Expiration Date: XXXXXXX
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR
DISABILITY BENEFITS
1. NAME AND ADDRESS OF EMPLOYER OF VETERAN (Complete)

2. ADDRESS (Complete)

RETURN
TO

INSTRUCTIONS: The veteran named in Item 3 has filed a claim for veterans disability benefits and has stated that he/she was recently employed by you. In order to
arrive at a fair decision in this case, we need the information requested below. Please complete Sections II, III and IV and return to this office at the address below.
Please be sure to sign and date this form in Items 23A and 23B. For free help in completing this form, call VA toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the Federal number is 711.
Where to Send Correspondence - After completing the form, mail to:
Department of Veterans Affairs
Evidence Intake Center
P.O. Box 4444
Janesville, WI 53547-4444
SECTION I - IDENTIFICATION INFORMATION

NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
3. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)

5. VA FILE NUMBER (If applicable)

4. SOCIAL SECURITY NUMBER

6. DATE OF BIRTH
Month

Day

Year

SECTION II - EMPLOYMENT INFORMATION (To be completed by employer)
7. BEGINNING DATE OF EMPLOYMENT
Month

Day

8. ENDING DATE OF EMPLOYMENT

Year

Month

Day

10. AMOUNT EARNED DURING 12 MONTHS PRECEDING LAST DATE OF
EMPLOYMENT (BEFORE DEDUCTIONS)

9. TYPE OF WORK PERFORMED
Year

11. TIME LOST DURING 12 MONTHS PRECEDING LAST DATE OF EMPLOYMENT
(DUE TO DISABILITY)

$
12A. NUMBER OF HOURS WORKED (Daily)

12B. NUMBER OF HOURS WORKED (Weekly)

13. CONCESSIONS (if any) MADE TO EMPLOYEE BY REASON OF AGE OR DISABILITY

14A. IF VETERAN IS NOT WORKING, STATE THE REASON FOR TERMINATION OF EMPLOYMENT:
(IF RETIRED ON DISABILITY, PLEASE SPECIFY)

15A. DATE OF LAST PAYMENT
Month

Day

Year

15B. GROSS AMOUNT
OF LAST PAYMENT

16A. WAS LUMP SUM
PAYMENT MADE?
YES

NO

14B. DATE LAST WORKED
Month

Month

$

SECTION III - RESERVE OR NATIONAL GUARD DUTY STATUS
(Only complete if claimant is currently serving in the Reserve or National Guard)
17A. WHAT IS THE VETERAN'S CURRENT DUTY STATUS?

17B. DOES THE VETERAN HAVE ANY DISABILITIES THAT PREVENT THEM FROM PERFORMING THEIR MILITARY DUTIES?
YES
VA FORM
XXXX

NO

21-4192

SUPERSEDES VA FORM 21-4192, SEP 2017,
WHICH WILL NOT BE USED.

Year

Day

Year

16B. DATE PAID

GROSS AMOUNT PAID

$

Day

VETERAN'S SOCIAL SECURITY NO.

SECTION IV - INFORMATION ON BENEFIT ENTITLEMENT AND/OR PAYMENTS (To be completed by employer)
18. IS VETERAN RECEIVING OR ENTITLED TO RECEIVE, AS A RESULT OF HIS/HER EMPLOYMENT WITH YOU, SICK, RETIREMENT OR OTHER BENEFITS?
YES

NO

(If "Yes," complete Items 19 through 21C)

19. TYPE OF BENEFIT

20. GROSS MONTHLY AMOUNT OF BENEFIT

$
21A. DATE BENEFIT BEGAN
Month

Day

21C. DATE BENEFIT WILL STOP (If known)

21B. DATE FIRST PAYMENT ISSUED
Year

Month

Day

Year

Month

Day

Year

22. REMARKS

I CERTIFY THAT the statements made in this form are true and complete to the best of my knowledge and belief.
23A. SIGNATURE OF EMPLOYER OR SUPERVISOR (Required)

23B. DATE SIGNED (MM/DD/YYYY)

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence
of a meterial fact, knowing it to be false, or for fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974
or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research
studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and
delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation,
Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. The
requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.
S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine eligibility for disability benefits based on unemployability (38 U.S.C. 1521). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this
form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of
information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired,
you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-4192, XXXX

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